Tuesday, March 13, 2007

High-deductible plan cuts ER use, study finds

People who changed their health insurance to a high-deductible plan went to emergency rooms 10 percent less often in the first year than people covered by traditional insurance, cutting down on their visits for such illnesses as colds, headaches and nausea, a study by Harvard Medical School and Harvard Pilgrim Health Care researchers shows.

High-deductible health plans are an important part of discussions in Massachusetts about how to make health insurance affordable as the state implements its new law mandating coverage for all citizens.

Previous studies, including the landmark RAND Health Insurance Experiment conducted almost 30 years ago, showed that making health care more expensive drives down the use of hospitals, medications and prevention services, whether needed or not.

The new study, which appears in tomorrow's Journal of the American Medical Association, came to a different conclusion: "Most HDHP (high-deductible health plan) members did not forgo high-severity emergency department visits and seemed able to distinguish low-severity conditions not requiring emergency department care." Dr. J. Frank. Wharam of Harvard and Harvard Pilgrim is the lead author.

The researchers also wanted to see if the drop in emergency department visits was followed by any change in hospitalizations that might suggest harm from a delay in seeking care. They didn't find such a link, but warn that their study was not designed to pick up this kind of association.

In an editorial commenting on the study, Dr. Corita R. Grudzen of the University of California at Los Angeles and RAND, and Dr. Robert H. Brook of UCLA make the point that a patient can't tell if a headache is serious or not.

"It is inconceivable that high-deductible health plans will not affect the health of some patients," they wrote. "If costs are to be constrained by less generous health insurance, some patients will be harmed."

The study analyzed emergency department visits and hospitalizations afterward among 8,724 people for one year before and after their employers switched from a traditional health-maintenance organization insurance plan to one that had a high deductible. They were compared to 59,557 people who stayed in the traditional HMO plan.

In high-deductible plans, monthly premiums are lower but patients must pay for most medical services, including emergency department visits and hospitalizations, up to a set level. The deductibles for people in the study ranged from $2,985 to $4,008 per year for family plans.

The rate of first visits that patients with high deductibles made to emergency departments wasn't different from those with traditional HMO coverage, but the number of second visits in that year fell 25 percent compared to the control group. That implies that once people get billed for an emergency visit, they are less likely to return, the authors said.

Patients still sought help in the emergency department for severe illness, the study found. But the authors warn that longer follow-up is needed to see if patients who defer care have worse health, particularly if they have low income.

"Our findings imply that, at least in the short term, HDHPs may be associated with reduced overall emergency department utilization without significantly affecting the highest-severity visits," they concluded. "Although we did not detect adverse outcomes, broad decreases in emergency department and hospital utilization raise concerns about long-term effects on health."

Responding to concerns raised in the editorial about harm to patients, Wharam said in an interview that high-deductible insurance plans might be offered by employers who would otherwise offer no coverage at all.

"It's possible that if the employer didn't purchase health insurance, the outcomes could be even worse," he said.

Massachusetts' new healthcare law presents a different case because it targets the uninsured population, he said, making it difficult to extend the study's results to it.

"The attempt to cover all Massachusetts residents is a noble one," he said. "I think the bottom line is that we need more research about how the high-deductible plans affect the behavior and outcomes of patients before making conclusive statements."

The study was funded by the Harvard Pilgrim Health Care Foundation and researchers were supported by federal and medical school grants and fellowships.